Romanian Hospitals Association Conference

1. Romanian Hospitals Association Conference Quality costs – “doing more with less” Anne Eden, CEO Buckinghamshire Healthcare NHS Trust 30/31 March Bucharest, Romania

2. Buckinghamshire Healthcare • 30 miles NW London • 2 acute hospitals 5 community hospitals Community Services in patient’s own homes Staff c6000 Income 2010/11 £345m Activity 100,000 emergency attendances 44,000 non-elective admissions 47,000 planned 458,000 outpatient appointments 2

3. Cost reduction programme 2008/9 – 2010/11 2008/92009/102010/112011/12 £9.6m £12.3m £29.8m £34m c£86m _________________________________________ Quality indicators Stroke √ A&E √ Cancer √ Access times √ Pressure Sore reduction √ Falls √ 3 3

4. Quality and productivity? • NHS needs to make unprecedented efficiency savings over the next three to four years → 2015 £20+billion • NHS facing some of the most significant financial challenges in its history – savings required of at least 4% year on year. • Office national statistics – 1996-2009 productivity declined by 0.2% (Hardie et al 2011) 4

5. Improved quality – reduced costs QIPP initiative – challenge in terms of sustaining quality and productivity 4 components: - Quality - Productivity - Innovation - Prevention Characteristics programme: earlier intervention fewer acute beds reduced unit costs Move away “cuts” focus on quality – clinical effectiveness/ safety/ patient experience 2010/11 NHS Operating Framework for England 5

6. Doing more with less • Reduce avoidable hospitalisation • Reduce average length of stay • Cost of staff singlest biggest item of expenditure • Variation in performance bring the worst up to the best • Use of IT improve processes, reduce costs/increase productivity/telehealth - telemedicine • Back office functions – simplify/standardise/share 6

7. QIPP initiatives in Bucks IV at home service(started July 2010) Team of community nurses and microbiologists Deliver IV antibiotic courses to patients in their own home or other community setting Patients would previously have remained in hospital until the course was finished Long and short course IVs e.g. joint, skin, cardiac, respiratory, UTI, cellulitis Evidence based – well established elsewhere 7

8. IV at home service Patient interviews established that they would prefer to be in their own homes (customer value) Reduces the impact of long hospital stays – loss of confidence, independence, risks of hospital acquired infections (removes delays/waste/ non-value) Reduces length of stay in hospital or enables admission avoidance altogether (cost) Patient can be fully supported to self manage their own treatment if appropriate (more efficient) 8

9. IV at home service Started July 2010 – now mainstream and evolving Number of bed days saved in first 8 months – over 2000, equivalent of 10 beds Number of patients treated - 140 Annual saving of £723k (@ £198 per bed day) Cost of service: £340k (staff, drugs, lines, travel) Net saving: £383k pa Total savings since inception £600k p.a. 9

10. IV at home service 6 month patient survey - level of satisfaction very high with all aspects of the service provision. 95% of the respondents stated the service was ‘very good’ • 'My treatment was very good - the idea of not having to stay in hospital was great.  The nurse was pleasant and well-mannered and made me feel comfortable around her in hospital and when she came to my home.  Totally recommend home care.  Thank you.' 10

11. COPD early supported discharge from hospital In England up to 3m people have COPD, but only 750,000 people are diagnosed – mostly at severe stage One in eight hospital admissions is for COPD; second most common cause of emergency admission to hospital Cost to the NHS about £1.5bn a year including drug costs 11

12. COPD supported discharge The evidence: Assisted-discharge schemes are a safe and effective alternative way of caring for patients with exacerbations of COPD who would otherwise need to be admitted or stay in hospital. The multi-professional team includes nurses, physiotherapists and occupational therapists Patients’ preferences about treatment at home or in hospital should be considered. NICE June 2010 12

13. COPD supported discharge Design workshop July 2010 attended by many stakeholders: 13

14. ‘Ideal’ service Rapid advice/support available by telephone Good written information Caring, protective service – I want to feel safe Access to 24 hour support/ advice in an emergency I don’t want to be trapped at home – I want to be able to get out and see my friends Signposting service I want my medicines to be easily available This is the picture drawn in the workshop to describe their ‘ideal’ service 14

15. COPD supported discharge – Re-engineered service no additional costs Key elements: Clear criteria for supported discharge Multi-disciplinary assessment Full, informed consent from the patient Clinical responsibility remains with hospital consultant Pharmacy support with compliance issues GP letter on discharge Home visit on day of discharge from a COPD specialist nurse, subsequent visits as needed Daily monitoring – tele medicine Patient leaflet detailing contact numbers 24/7 Links to GP and Out Of Hours service Patient held notes Direct access to specialist medical advice Links to pulmonary rehabilitation, smoking cessation and other life style services 15

16. COPD supported discharge Outcomes: Patients spend on average 7 fewer days in hospital “***** and her team were fantastic and I have nothing but praise.” “I cannot speak highly enough about the discharge support service. It was particularly pleasant being treated on such a personal level by the relevant member of staff. The connection between the GP, hospital staff and the COPD support scheme was reassuring. Thank you.” Saving per patient:£1200, est pa: £90k 1:8 hospital admissions - COPD 16

17. Doing more with less Common themes: Ensure clinical/executive support for the need to change Analyse the whole system/process to identify where the real problems lie and where savings and improvements can be made Place the patient/customer needs and values at the centre of the redesign Involve all stakeholders - communicate Be clear about objectives, timescales and outcome measures from the beginning Be clear about responsibilities and roles during the change and once the change is live - sustainability Don’t cut corners – real change is hard and takes time 17

18. “Two practical examples – more with less” … IV antibiotics @ home … COPD assisted discharge Improved quality of the service patient experience safety outcomes Reduced the cost to the system QIPP - √ Slash & burn X 2010/11 – Alongside financial accounts, quality accounts Quality costs - reduce variation - reduce avoidable harm - get it right the first time 18